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Weight Loss Surgery Doesn't Cut Health Costs

 |  By cclark@healthleadersmedia.com  
   February 21, 2013

A report concluding that weight loss surgery in 29,820 obese BlueCross BlueShield enrollees did not result in lower health costs compared with similar enrollees who didn't have the procedure is being attacked by bariatric surgeons who say the research was "irresponsible."

The study, by Johns Hopkins University health economists, found that while those who had the surgery had lower costs for medication and physician's office visits up to six years later than a similarly obese group that did not undergo surgery, those reductions were overcome by much higher hospital costs in the surgery group.

"They were in the hospital more often" compared with the group that didn't have surgery, says Jonathan Weiner of the Johns Hopkins Bloomberg School of Public Health, the study's principal author. The study is published in JAMA Surgery.

"We didn't delve so much into why, but there are a couple of reasons. One is they could have had complications (from their original surgery), or they may have come in for related surgery, like plastic surgery after their bariatric procedure," Weiner says. "And here's a hypothesis, some are coming back in for 'good' surgery – they couldn’t get a hip or knee replacement before (because of their weight), but now they can."

"Someone could come back and say, 'but bariatric surgery improved my life; I was less likely to have a heart attack.' Some studies have shown those kinds of things," Weiner says. But this study didn't address those issues.

"We didn't measure the quality side of the equation," he says. All they looked at was whether the $29,000 cost of the surgery (in 2005 dollars) was made up in lower costs during the ensuing six years. "It does not suggest that the cost for that surgery is made up in savings after the surgery." The cost of the index bariatric procedure was not included in the calculations.

The study's examination of cost data, Weiner says, indicates that patients in the surgical group did lose weight, and did get healthier. But in time, they put weight back on, and costs "may creep back up over time."

Bariatric surgery is performed in about 200,000 patients a year, ostensibly to improve quality of life and reduce risk of heart and metabolic disease. An estimated $168 billion, or 15.5% of the nation's healthcare expenditures, are spent annually to treat obesity and its associated comorbidities.

Weiner says that knowing the surgery doesn't lower healthcare costs can be useful for organizations, public or private payers, or health systems that develop guidelines for providing bariatric surgery. "I don't think it will really impact any doctor or patient for their immediate decision on whether or not they should get surgery. But it does add to our knowledge base of the long-term trade-off of a major medical procedure."

But Robin Blackstone, MD, immediate past president of the American Association for Metabolic and Bariatric Surgery and Medical Director of Scottsdale Healthcare Bariatric Center, took the paper and its methodology apart, even suggesting "it was irresponsible for them to publish it."

For starters, she says, the researchers used claims data between 2002 and 2008, a period when many bariatric procedures were performed with riskier open surgical incisions rather than the current laparoscopic techniques. In fact, the original method of open gastric bypass, one of five types of bariatric procedures performed, accounted for more than one-third of the operations.

Additionally, she says, it's inappropriate to do such a cost analysis because similar studies aren't done for surgeries for other conditions, like heart disease or lung cancer.

"I think we all need to realize that for individual who are obese, having surgery makes a huge difference in their lives. I see patients with diabetes, on 20 different meds all with bad side-effects, constantly seeing the doctor, not productive at work, exhausted because of painful joints, who are having trouble being good partners or good parents. And to see all of that reversed and [to see] people becoming re-engaged is so valuable," Blackstone said.

"If this were lung cancer or heart disease, we wouldn't be having this conversation."

John Morton, MD, the association's secretary-treasurer and the Stanford University School of Medicine's director of Quality Surgery and Surgical Sub-specialties, added that because the two groups were not strictly matched by BMI, it may be that the comparison group was essentially healthier to begin with.

He also suggested that the reasons bariatric surgery patients have surgery represents "pent up demand" for procedures they may have wanted to have, but weren't appropriate for previously because of their unhealthy weight, "but now that obstacle is removed."

"We know obesity is a leading public health problem this country, but here, when we have something that actually works, and is safe, it's being attacked for not providing cost savings when there's no similar criteria for any other disease. There's bias we feel has come into play."

Clifford Ko, MD, director of the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP), also had a criticism: "No study is perfect but they should at least address the limitations more appropriately. All studies should."

In a related editorial, Edward H. Livingston, MD, JAMA deputy editor, wrote that the study suggests "weight loss operations should be offered to highly selected patients," those with a complication of obesity "that is known to dramatically improve with weight loss surgery.

Examples include diabetes and osteoarthritis. These operations should not be done for body mass index as an exclusive indication," and, he added, only patients "with demonstrated compliance to medical and dietary treatment" should be offered the procedure.

Weiner says the seven BlueCross Blue Shield plans provided data for 18 million people, some 29,800 of whom had bariatric surgery and qualified for inclusion.

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